Elementos doctrinales

The last trial, Johnson and Zlotnick, compared IPT with psychoeducation.35 Participants in the IPT group attended manualized group treatment sessions three times per week for 8 weeks while incarcerated and 6 weekly postrelease individual sessions. IPT sessions targeted such areas as disrupted relationships with family and friends and coping with loss. Participants in the

focused on teaching participants about mental health issues and their relationship to substance abuse, providing medication-specific information, and about resources available in the

community. Participants were observed for 3 months after treatment.

Subjects in the Johnson and Zlotnick trial received standard-of-care substance-abuse treatment in prison in addition to receiving the study treatment, and more than half of all subjects were on antidepressants.35 Treatment fidelity was noted to be very high in this trial. See Tables E7 and E8 in Appendix E for these and other treatment characteristics. Subjects were prison inmates due to be released in 10–24 weeks with both major depressive disorder and substance abuse diagnoses. The study enrolled female subjects in their mid-30s, the majority of whom were unmarried and Caucasian. The authors did not report patient education level, but 74 percent had an annual income of less than $10,000.

Johnson and Zlotnick did not report the percentage of participants with convictions for violent crimes, but the median number of arrests was 4 and 6 in the psychoeducation and IPT arms, respectively.35 This study did not report on felony conviction status or Medicaid enrollment upon study entry. See Tables E9 and E10 in Appendix E for more detail.

Participants had disease diagnoses based on the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders Axis I disorders and for substance-use disorders. All participants had a primary (not substance induced) diagnosis of major depressive disorder and a substance use disorder. Co-occurring personality disorders, including borderline personality disorder and antisocial personality disorder, were present in a quarter to one-half of study subjects.35 See Table E10 in Appendix E for further detail.

Findings

Johnson and Zlotnick measured change in psychiatric symptoms and substance abuse.35 They reported that by the 3-month followup, both groups experienced a reduction in their depressive symptoms as measured by the mean HRSD, with no difference by treatment group (15.8 [SD, 11.7] and 12.0 [SD, 12.3] for the IPT and psychoeducation groups, respectively). Likewise, the two groups experienced similar rates of substance-abuse relapse after being release from incarceration (9/19 [47 percent] and 6/19 [32 percent] for the IPT and psychoeducation groups, respectively). See Tables F10 and F14 in Appendix F and Table 18 below for more information.

Table 18. Strength-of-evidence grade for studies assessing interpersonal therapy versus psychoeducation treatment for Key Question 2

Comparison Outcome Number of Studies (Number of Patients) Overall Risk of Bias

Consistency Directness Precision Evidence Favors SOE Grade IPT vs. psychoeducation Psychiatric symptoms, substance abuse 1 (38) Low Unknown (1 study)

Direct Imprecise — Insufficient

IPT = interpersonal therapy; SOE = strength of evidence

Applicability

The single trial that compared IPT with psychoeducation enrolled women in their mid-30s with dual diagnoses of major depressive disorder and substance abuse.35 They had a median of

five prior arrests, and from 25 percent to 50 percent had a co-occurring personality disorder. The findings presented here may be applicable only to this subset of inmates. See Tables E9 and E10 in Appendix E for more detail.

Discussion

Key Findings and Strength of Evidence

This review covered the treatment of offenders with serious mental illness (SMI). This is a population that has trouble coping with prison life and is more likely to return to incarceration following release than offenders without SMI.

Two studies (low strength of evidence) suggest that providing incarcerated inmates with antipsychotics other than clozapine may improve psychiatric symptoms better than treatment with clozapine.68,69

Two studies (low strength of evidence) suggest that providing inmates with discharge planning that includes Medicaid application assistance is likely to increase their use of mental health services upon release.78,79 Theoretically, increasing individuals’ use of mental health service will lead to better control of their mental health symptoms, which, in turn, may lessen future contacts with the criminal justice system.

The findings of this review also suggest that providing offenders who have dual diagnoses with a comprehensive, integrated dual disorder treatment (IDDT) intervention increases mental health service use both during and after release from incarceration and may reduce psychiatric hospitalizations better than standard of care (low strength of evidence).78,81,82 See Table 19 below for more detail.

Table 19. Summary of findings for Key Question 1 and Key Question 2

Key Question Comparison Outcome SOE Grade

Key Question 1 – incarceration setting

Clozapine vs. other antipsychotics Psychiatric symptoms Low in favor of antipsychotics other than clozapine Clozapine vs. other antipsychotics Independent functioning Insufficient Risperidone vs. other

antipsychotics

Psychiatric symptoms; institutional infractions

Insufficient High dose chlorpromazine vs.

standard dose

Psychiatric symptoms Insufficient Cognitive problem solving group

(R&R) vs. treatment as usual

Psychiatric symptoms Insufficient Cognitive group therapy vs.

individual supportive therapy

Psychiatric symptoms Insufficient Modified therapeutic community

vs. intensive outpatient

Psychiatric symptoms; substance abuse; criminal justice outcomes

Insufficient

Modified therapeutic community vs. standard mental health treatment

Psychiatric symptoms; substance abuse; criminal justice outcomes

Table 19. Summary of findings for Key Question 1 and Key Question 2 (continued)

Key Question Comparison Outcome SOE Grade

Key Question 2 – incarceration-to- community transition setting

Discharge planning with benefit- application assistance vs. no application assistance

Mental health service use upon releasea

Low in favor of discharge planning with benefit-

application assistance Intensive jail treatment followed by

high-fidelity IDDT vs. intensive jail treatment followed by treatment as usual

Psychiatric symptoms (crisis visits)

Insufficient

IDDT vs. treatment as usual in the community

Psychiatric hospitalization (administrative records)

Low in favor of IDDT Mentally ill chemical abuser

treatment vs. treatment as usual

Function (correctional facility agent reports)

Insufficient Mentally ill chemical abuser

treatment vs. treatment as usual

Medication adherence (correctional facility agent reports)

Insufficient

Mentally ill chemical abuser treatment vs. treatment as usual

Substance use (urinalysis) Insufficient IDDT vs. treatment as usual in the

community

Mental health service use upon release

(administrative records)a

Low in favor of IDDT

IDDT vs. treatment as usual Mental health service use during incarceration (administrative records)a

Low in favor of IDDT

Mentally ill chemical abuser vs. treatment as usual Institutional infractions (time in segregation; conduct reports) Insufficient Interpersonal therapy vs. psychoeducation Psychiatric symptoms (HRSD); substance abuse (urinalysis) Insufficient a Intermediate outcome

HRSD = Hamilton Rating Scale for Depression; IDDT = integrated dual diagnosis treatment; R&R = Reasoning and Rehabilitation; SOE = strength of evidence

Findings in Relationship to What Is Already Known